Tracheoesophageal fistula with esophageal atresia


Palmer, AK
Best answers
I could really use some guidance/expertise in coding this one. So far, I'm using Dx: Q39.1, P07.37; CPT 43314 and 31622.


Preoperative Diagnosis: Tracheoesophageal fistula with esophageal atresia
Postoperative Diagnosis: Tracheoesophageal fistula with esophageal atresia

Procedure Performed: Rigid bronchoscopy, flexible bronchoscopy, ligation of tracheoesophageal fistula with repair of esophageal atresia via right thoracotomy

EBL: 5 mL
Drains: Right chest tube to -10 cm H20 suction. NG (trans-anastomotic) tube capped.
Complications: None
Specimen: None

Indications: Boy (baby) is a 0 day old male with multiple congenital anomalies who presents with a newly diagnosed TEF. The child was premature, born at 34 weeks. The patient was born with prenatal polyhydramnios and then an inability to pass an OG after birth. The patient also has numerous limb defects and facial anomalies. A TTE showed a left sided arch but difficult to assess the origins of the PAs, as well as a large PDA. The patient was not ventilating and oxygenating well without positive pressure and therefore the patient was expedited to the OR. The patient was then indicated for bronchoscopy and TEF repair. The risks and benefits of the procedure were discussed with the parents who agreed to proceed.
Patient Weight: Birth weight 1830 gm

Findings: Tracheoesophageal fistula 1 cm proximal to carina on bronchoscopy. Right thoracotomy with entry into pleural cavity. Esophageal atresia with distal tracheoesophageal fistula (type C) present. Ligation of tracheoesophageal fistula. Esophageal atresia with ends approximately 2 - 3 cm apart prior to dissection. Esophageal anastomosis under some tension and performed over a nasogastric catheter. Right chest tube to -10 cm suction.

Procedural Details: The patient was identified in the NICU. PARQ was held, questions answered and consent obtained for the above procedures. The patient was brought to the operative suite and placed in the supine position. Time out was performed to verify correct patient, diagnosis, procedure, equipment and personel and all concerns were addressed. Preoperative antibiotics were given. General anesthesia was induced.

Rigid bronchoscopy was performed prior to intubation to document presence of a tracheoesophageal fistula. Final timeout was held and no concerns were raised. A laryngoscope was used to elevate the epiglottis and expose the vocal cords. A 3 rigid bronchoscope was passed under direct visualization between the vocal cords and into the trachea. The bronchoscope was advanced to the carina. On withdrawal of the scope a posterior fistula was observed 1 cm proximal to the carina. Careful inspection of the remainder of the trachea revealed no additional fistulas. The bronchoscope was removed and the patient was intubated by anesthesiology. After intubation I used a 2.2 flexible bronchoscope to complete a flexible bronchoscopy. This confirmed that the tip of the ET tube as across the fistula and just above the carina. The flexible bronchoscope was then removed.

The patient was positioned in a left lateral decubitus position with all pressure points padded. The right chest was then prepped with betadine and draped in usual sterile fashion. A #15 blade was used to make a transverse right posterolateral incision one finger breadth below the tip of the scapula. This was deepened through the subcutaneous tissues using electrocautery. A muscle sparing approach was made, creating subcutaneous flaps above the right latissimus dorsi and serratus anterior muscles. The serratus muscle was nearly non existent along with some other chest wall abnormalities including bifid ribs. The plane between the right latissimus dorsi and serratus anterior muscles was developed and the avascular plane between the latissimus and the chest wall was then developed using electrocautery. The fourth rib was identified and the thoracic cavity was carefully entered by dividing the intercostal muscles in the 4th intercostal space, just along the superior aspect of the 5th rib. An extrapleural approach was attempted and the pleura was swept medially off the lateral and inferior chest wall using moistened qtips and a moist reytec. Several large tears in the pleura were left unrepaired. The pleura was abnormally adhered to the other chest wall anomalies superiorly and laterally. A Finocchietto rib spreader was then placed and used to separate the fourth and fifth ribs and provide visualization.

The azygos vein was identified, dissected circumferentially, and occluded with a silk tie with no change in the infant's hemodynamics or saturations. The azygos vein was then ligated with 3-0 silk ties and divided with metzenbaum scissors. Just deep and superior to the divided azygos, the tracheoesophageal fistula was identified. The fistula was circumferentially dissected. The vagus nerve was identified and avoided. Once completely dissected, temporary occlusion of the fistula was performed using vessel loop and demonstrated persistent ventilation of the right lung. The right mainstem bronchus could be palpated as a separate structure from the identified fistula. The fistula was then ligated sequentially with several interrupted 5-0 prolene sutures and divided with sharp scissors. A leak test was performed by submerging the fistula tracheal stump in sterile saline with no bubbling or evidence of a leak noted.

The replogle was then pressed into proximal pouch by anesthesia. A 3-0 silk was sutured to the esophagus and the replogle of the proximal pouch and used for retraction. The distal esophagus and proximal esophageal pouch were approximately 2 cm apart with tension on both ends. The proximal pouch was carefully mobilized circumferentially using a combination of blunt dissection, tenotomy scissors, and electrocautery. There was no injury to the trachea. The dissection was carried superiorly to the thoracic inlet. The distal esophagus was dissected using a combination of blunt dissection, and electrocautery down to the level of the diaphragm and a small amount of stomach was pulled into the chest. After dissection the two ends of the esophagus were able to be approximated with mild tension. A transverse esophagotomy was made in the proximal pouch. An esophagoesophagostomy was then performed bringing the proximal pouch and distal esophagus together. A hand sewn end to end anastomosis was performed using interrupted full thickness 4-0 vicryl sutures. The anastomosis was high in the chest as the proximal esophageal pouch was quite retractile and not very long despite disseciton up to the thoracic inlet. A couple of the back rows of suture ripped through the proximal pouch but were able to be replaced with large bites of tissue and then was able to be approximated. Once the back row was sewn in place, a 5 Fr feeding tube was advanced to a nasogastric position and the anterior row of sutures was placed over the tube. Medial to the anastomosis a small amount of pleura was dissected and used as a patch between the tracheoesophageal fistula ligation and the esophagoesophagostomy. This appeared to be sufficient in covering the prolene fistula ligation sutures. Hemostasis was confirmed.

A 12 fr chest tube was then placed. A #15 blade was used to make a small transverse incision inferior and medial to the thoracotomy. A hemostat was used to bluntly penetrate the thoracic cavity one intercostal space below the thoracotomy and the 12 fr chest tube was grasped through the skin incision and brought into the thoracic cavity in a lateral apical position. The tube was secured externally to the skin.

The ribs were reapproximated with vicryl interrupted pericostal sutures. The latissimus muscle fascia was reapproximated to the serratus with an interrupted 3-0 vicryl. 4-0 vicryl deep dermal suture were placed. The skin was closed with a running subcuticular 5-0 monocryl. Dermabond was applied. The chest tube was connected in sterile fashion to the pleurovac. The chest tube was dressed with a sterile gauze and tegaderm and placed to negative 10 cm H20 suction.

All sponge, instrument, and needle counts were correct at the end of the case. Patient tolerated the procedure well and remained intubated for transport to the NICU.